Your name

Your email

Phone

Date of birth

Address

Country

Emergency Contact

Date of planned ceremony

1. Are you currently taking any medication/s?
YESNO
If yes tell me about it. (Name of Medication, Dose, How Long, how it`s affecting you?)

2. Do you have any chronic illnesses? YESNO
If yes, Tell me about it. (Illness, Condition, How long, Treatment, How do you feel now?)

3. Do you have any current medical conditions?YESNO
If yes, Tell me about it. (Condition, How long, Treatment, How do you feel now?)

4. Do you have any fears or phobias?YESNO
If yes, Tell me about it.

5. Do you or have you in the past suffered from a psychological disorder?YESNO
If yes, Tell me about it.

6. Are you currently taking any medication for any psychiatric disorder?YESNO
If yes, Tell me about it. (what are you taking and how much)

7. Have you experienced seizures or been diagnosed with epilepsy?YESNO
If yes, Tell me about it.

8. Do you use stimulants and/or drugs?YESNO
If yes, Tell me about it. (what, How often, How much?)

9. Do you drink alcohol?YESNO
If yes, Tell me about it. (how often, how much?)

10. Do you have a drug or alcohol addiction?YESNO
If yes, Tell me about it.

11. Have you had an operation or surgery of any kind recently?YESNO
If yes, Tell me about it.

12. Do you have a cardiovascular problem?YESNO
If yes, Tell me about it.

13. Is there anything about your physical/mental state I should know about?YESNO
If yes, Tell me about it.

14. Do you have previous experience working with Kambo treatment?YESNO
If yes, Tell me about it.

I hereby certify that I have accurately and truthfully completed the above Participant Form.
YESNO

**The information provided is for the needs of the planned/ongoing therapy will be destroyed after completion.

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